Safe Transitions LAN Event

Transcription

1 Safe Transitions LAN Event Rhode Island s Community Approach To Safe Transitions One Year Later What We Did, What We Achieved, and What We Learned Along The Way Event Details Date / Time: Thursday September 20, :30am-11:30am (registration opens at 7:00am) Agenda Registration Check-in Welcome Lynne Chase / Stefan Gravenstein, MD, MPH ~ Healthcentric Advisors Provider presentations Reducing Readmissions through appropriate End of Life Care o Presentations facilitated by Therese Rochon, MSN, MA, RNP, ACHPN ~ Home and Hospice Care of Rhode Island Jennifer Cellar, RNP ~ Evergreen House End of Life Planning: The importance of having the conversation Nancy Forte BSN, RN ~ Home Care & Hospice of New England Partnering in the Care of Advanced Illness: Educating patients and providers on specialized Palliative and Hospice care Communication Matters! Providing Effective Patient Education and Post- Discharge Follow Up o Presentations facilitated by Rebekah Gardner, MD ~ Healthcentric Advisors Amy Paul, RN, BSN, CCM ~ Memorial Hospital Using post discharge outbound calls to influence readmission rates Carol Bramley, RN, BSN, Linda Zabbo, RN, BSN, and Jennifer Gillis, NP, MSN~ VNA Care New England Heart Failure Program Pilot Overcoming Medication-Related Barriers o Presentations facilitated by Stephen J. Kogut, PhD, MBA, RPh ~ University of Rhode Island College of Pharmacy Jackie Costantino, RPh, MBA ~ South County Hospital Medication Reconciliation Transitions of Care Lynne Driscoll, RN, CCM ~ South County Hospital Improving medication management during transitions of care A collaborative effort Debrief Session Therese Rochon, MSN, MA, RNP, ACHPN, Rebekah Gardner, MD, and Stephen J. Kogut, PhD, MBA, RPh Wrap Up & Next Steps Lynne Chase ~ Healthcentric Advisors 7:00am - 7:30am 7:30am 7:45am 7:45am 8:35am (Round 1) 8:35am - 9:25am (Round 2) 9:25am - 9:45am BREAK 9:45am - 10:35am (Round 3) 10:35am - 11:20am 11:20am - 11:30am Provided by Healthcentric Advisors, the Quality Improvement Organization for Rhode Island

2 Rhode Island s Community Approach to Safe Transitions - One Year Later: What We Did, What We Achieved, and What We Learned Along the Way (The PDSA Way) Provider Poster Presentations Safe Transitions Learning & Action Network Event September 20, 2012

3 Reducing Readmissions through appropriate End of Life Care Presentations facilitated by: Therese Rochon, MSN, MA, RNP, ACHPN ~ Home and Hospice Care of Rhode Island Jennifer Cellar, RNP ~ Evergreen House End of Life Planning: The importance of having the conversation Nancy Forte BSN, RN ~ Home Care & Hospice of New England Partnering in the Care of Advanced Illness: Educating patients and providers on specialized Palliative and Hospice care Safe Transitions Learning & Action Network Event September 20, 2012

4 End of Life Planning The Importance of Having the Conversation Jennifer Cellar, RNP Evergreen House Providence Transitions Coalition (PTC)

5 Advanced Directive Planning Leading cause for hospital re-admissions is lack of discussion surrounding advanced directives. 61% population have preferences about the medical care/interventions they would receive if they were unable to make decisions Only 34% population had signed advanced directives depicting their wishes (Verna & Leon, 2010)

6 Importance of Having the Conversation Goal to facilitate discussion of advanced directives Provide education about interventions Improve family members understanding of basic terms Increase comfort level with making advanced directive decisions.

7 Intervention Collaborative effort between: Evergreen House (Dr Dennison, Jennifer Cellar RNP) Hospice & Palliative Care Terry Rochon (Director of Palliative Care) Denis Lynch (Hospice Chaplain) Evercare (Michelle Debeste, CSM) Event to bring families together for discussion of advanced directives Video viewing Discussion Presentation of advanced directives

8 Video Viewing When Doctors and Daughters Disagree: twenty-two days and two blinks of an eye (Abadir, Finucane & McNabney, 2011) Examine one families struggle with end of life decisions Panel members to facilitate discussion and answer questions. Spurred discussion about participants own experience with making medical decisions Polar views about wishes expressed

9 Education Presentation of basic information about advanced directives. Reviewed current laws/terms Role of POA-HC Types of advanced directives Benefits and burdens of interventions CPR -Repeated hospitalizations Artificial Nutrition Intubation

10 Evaluation Pre-test and Post-test used to assess participants baseline understanding of information and effectiveness of discussion/education. Simple 3 question format used to improve compliance Identical questions asked in written format before and after to determine effectiveness of lecture and discussion Participation of pre and post test requested but not required

11 Pre/Post Test I feel comfortable making end of life decisions. Circle your level of comfort. 1 being not comfortable and 7 being very comfortable What are the two most common forms of advanced directives? A) Health Care Proxy B) Living Will C) Financial Will What is the role of the person who has been elected to be the Power of Attorney for a patient? A) To make decisions based on their wishes for the patient B) To make decisions based on what the patient wants C) To make decisions based on what the family wants D) To make decisions based on what the doctor says or feels

12 Results Findings suggest improved understanding of role of POA-HC Intervention did not reflect increase comfort level in making EOL decisions Findings may be related to other factors including literacy level of participants and participation Increased understanding of decision making may contribute to decreased comfort level Findings may also reflect more educated decision making

13 Next Steps Continued advanced directive education to patients and families Encourage discussion and documentation of wishes Review risks and benefits of interventions to ensure educated decisions Continued collaboration with Evercare, Palliative Care and Hospice

14 The PDSA Way Partnering in the Care of Advanced Illness: Educating patients and providers on specialized Palliative and Hospice Care Nancy Forte BSN, RN Home Care & Hospice of New England Director of Growth Strategies

15 Plan Background It is widely recognized that despite patient preferences to die at home, a large percentage of patients at End of Life (EOL) die in the hospital. Impacts quality of life for both patient and family Increases the financial burden incurred due to unnecessarily aggressive care 1 February of 2012, VNHC and HHCRI formally affiliate With the approval of the DOH, the two independent non-profit agencies formed a synergistic relationship to serve the community Goal Patient receives the right care, at the right time in the right place as evidenced by reduced ED visits and hospital readmissions 1. Goodman, DC et al. Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness. The Dartmouth Atlas Project, 12 April 2011 Safe Transitions LAN, 9/20/12

16 Do Intervention Collaborative education was provided by HHCRI educators to VNHC staff (including Nurses, Therapists, Home Care Aids and Medical Social Workers) to expand and improve upon the care of patients with advanced illness: FY 12, Q1: Assisting Patients & Families to Navigate Difficult Medical Decisions FY 12, Q2: The Concepts and Practice of Hospice & Palliative Care FY 12, Q2: Advance Directives Safe Transitions LAN, 9/20/12 4

17 Study Evaluation/Data (Goal: Patient receives the right care, at the right time in the right place, as evidenced by reduced ED visits and hospital readmissions.) We plan to measure the following indicators: Comfort level of nurses with difficult EOL conversations Hospice and Palliative Care referrals Number of patients who obtain Advance Directives Safe Transitions LAN, 9/20/12 5

18 Study Results Regular review of patient needs and goals of care Identified a need to expand and improve clinical skills Identified and filled new positions Care Transition Coordinator Director of Clinical Informatics Dedicated Clinical Staff Educator Safe Transitions LAN, 9/20/12 6

19 Act Next Steps: Opportunities for future internal and external collaboration include: Expanded services in the home Continued State-wide EOL care education focusing on palliative vs. curative thinking Barriers Resistance of clinicians to discuss EOL options with patients Fear and lack of understanding of terms like hospice and palliative by both clinicians and patients/families Regional tendency to utilize unnecessarily aggressive care in the last 6 months of life 2 2. Goodman, DC et al. Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness. The Dartmouth Atlas Project, 12 April 2011 Safe Transitions LAN, 9/20/12 7

20 Collaboration The PDSA Way Advice for others Patience, persistence, passion, vision Be a Fire Starter 3 Partnership opportunities Pharmacists, Urgent Care Centers, ER Staff, Ambulance Services Technology partners 1. Studer, Quint. Hardwiring Excellence. Gulf Breeze, FL: Firestarter Publishing, 2003 Safe Transitions LAN, 9/20/12 8

21 Thank you! The PDSA Way Questions? Safe Transitions LAN, 9/20/12 9

22 Communication Matters! Providing Effective Patient Education and Post- Discharge Follow Up Presentations facilitated by: Rebekah Gardner, MD ~ Healthcentric Advisors Amy Paul, RN, BSN, CCM ~ Memorial Hospital Using Post Discharge Outbound Calls to Influence Readmission Rates Carol Bramley, RN, BSN, Linda Zabbo, RN, BSN, and Jennifer Gillis, RN, MSN~ VNA Care New England Heart Failure Program Pilot Safe Transitions Learning & Action Network Event September 20, 2012

23 The PDSA Way Development of a Post Hospitalization Outbound Call Program Amy Paul, RN, BSN, CCM Director, Continuing Care amy_paul@mhri.org Northern Rhode Island Coalition

24 Plan Background Opportunity: MHRI s Medicare 30 day overall readmission rate to the same or another hospital was 25.3% in Q2 of FY 2011* Systems analysis: Goal *Medical record audit of readmission events *Patient interviews using IHI STAAR tool *Interviews with Case Managers / anecdotal reports from Nurses, Homecare Practitioners, and Post Acute Care Providers The Medicare 30 day readmission rates for pneumonia, heart failure, and acute MI will be reduced by 20% over the next three years. Safe Transitions LAN, 9/20/12 * PEPPERresources 3

25 Do Intervention/Project Implementation of post discharge outbound calls to patients was chosen for testing *streamlined four question assessment *question content built around known drivers and risk factors for readmission *scripting based upon tenets of motivational interviewing Project participants and partners: Continuing Care clinicians (Case Managers), Case Manager from MHRI Family Care Formal evaluation of intervention to occur Q2 FY 2013 Safe Transitions LAN, 9/20/12 4

26 Study Evaluation/Data Outcomes measure: Medicare 30 day overall readmission rate to the same or another hospital Operational measure: Number of discharged patients who engaged in an outbound call within 3 business days of hospital discharge* Proximal outcome measure: Patient satisfaction Balance measure: Average length of stay Results Patient identification need not be static, but any changes to the population targeted must be tracked to support validation of outcomes data Baseline: 25.3% in Q2 FY 2011 Now: 22.2% in Q2 FY 2012 Safe Transitions LAN, 9/20/12 *Exclusions: discharges from observation level of care, maternity / nursery discharges, select Family Care patients, discharge dispositions other than home 5

27 Act Next Steps Improved transitions of care will result in decreased avoidable readmissions and increased patient satisfaction Streamline patient discharge teaching materials for maximum value and engage Nurses in evidence based discharge teaching interventions Leverage oversight, guidance, and operational support from MHRI Transitions of Care Team to support successes over time Barriers Finite resources Operational reporting and patient identification for programs are currently manual processes Safe Transitions LAN, 9/20/12 6

28 Collaboration The PDSA Way Advice for others Organizational support is critical; enlist a project champion Establish oversight via a multidisciplinary workgroup with representation from many practice and care settings Partnership opportunities Collaborating with external entities: Safe Transitions Learning and Action Network, the Hospital Engagement Network, and the Partnership For Patients Collaborating with other MHRI crossfunctional teams: Performance Improvement Committee, Patient Flow Committee, Utilization Review Committee Working with providers of post acute levels of care is critical Safe Transitions LAN, 9/20/12 7

29 The PDSA Way Heart Failure Program Pilot VNA of Care New England Carol Bramley, RN, BSN Linda Zabbo, RN, BSN Jennifer Gillis, NP, MSN Safe Transitions Learning & Action Network Event

30 Plan Targets for Improvement: Reduce 30-day hospital readmission rate for heart failure patients. Improve MD and VNA communication and collaboration in care management of CHF patients Safe Transitions LAN, 9/20/2012 3

31 Plan Targets for Improvement: Standardize home care education plan for heart failure patients Improve early intervention of symptom management by VNA staff and self management by patients. Enhance staff education regarding the care of HF patients Safe Transitions LAN, 9/20/2012 4

32 Plan AIM Statement: Improve overall patient experience, increase symptom management skills and reduce re-hospitalization by 20% by September 30, 2012 Safe Transitions LAN, 9/20/2012 5

33 Do Project: Develop a Home Health and Hospital Collaborative Care Model and improve the safe transition of heart failure patients from hospital to home, increase patient self management skills and reduce the hospital re-admission rate of HF patients Safe Transitions LAN, 9/20/2012 6

34 Do Interventions: Upgraded remote monitoring technology to provide more effective symptom management Developed a dedicated team of nurses to follow remote monitor transmissions 7 days a week / Begin remote monitoring within 24 hours of SOC Enhanced use of SBAR communication between VNA staff and physicians Employed a nurse practitioner to provide staff education / HF patient consultation visits Safe Transitions LAN, 9/20/2012 7

35 Do Interventions: Developed new HF patient education handbook / new HF care pathway Began bi-monthly meetings with the Kent Hospital HF pilot team for program collaboration and case management Collaborated with Kent Hospital HF team to standardized HF Zone education to be used across the continuum of care Safe Transitions LAN, 9/20/2012 8

36 Do Who is Involved? VNA of Care New England Kent Hospital Department of Cardiology Patients and their families Safe Transitions LAN, 9/20/2012 9

37 Do Timeline: January, NP began performing cardiac consult visits for HF patients, installation of new remote monitoring system, staff education regarding SBAR communication and chronic care management May, developed staff education program for management of HF patients, developed new HF patient handbook, and new HF care pathway July, began discussions with Kent Hospital to begin collaboration for a HF patient pilot program September, Launch of Kent Hospital collaboration HF patient pilot program Safe Transitions LAN, 9/20/

38 Study Evaluation: VNA HF patient readmission rate to Kent Hospital within 30 days Self Care Index to measure pre and post self care maintenance ability and adherence to prescribed medication regimen Compliance with MD HF clinic follow up VNA SN feedback Safe Transitions LAN, 9/20/

39 Study Results: Increased remote monitoring units to 60 Developed and tested HF care path and added NP consult visit to path Provided additional cardiac care education to staff Educated all staff about SBAR Implemented revised patient symptom management tool Reduced re-hospitalization rate by 35% Safe Transitions LAN, 9/20/

40 Act Next Steps: Begin patient enrollment into the HF patient pilot program in collaboration with Kent Hospital Department of Cardiology Evaluate care path / staff and patient adherence to visit schedule Assess patient participation in structured education program and improvement in patient self management (Self Care Index) Safe Transitions LAN, 9/20/

41 Act Next Steps: Expand number of patients followed by remote monitoring Transition patients from daily remote monitoring to daily self initiated reporting To establish additional MD partnerships to expand and enhance our HF homecare program and ensure optimal care for our HF patients Safe Transitions LAN, 9/20/

42 Act Ensuring Success: Develop standards of care Electronic record auditing Adherence to care pathway Ongoing staff education and feedback 6 month evaluation of pilot program successes and areas needing revision Safe Transitions LAN, 9/20/

43 Collaboration Project Barriers: Change in staff practice Patient compliance MD collaboration Recommendations for Others: Form a team and collaborate among multi-disciplines Frequent review and flexibility to modify plan as necessary Safe Transitions LAN, 9/20/

44 Collaboration Partnership Opportunities: Develop programs to include additional chronic conditions (stroke, COPD) Begin collaborative partnerships with additional home medical groups and private practices Partnership Needs: MD collaboration Integrate with cardiac team at Kent Hospital Integration of electronic patient medical record Safe Transitions LAN, 9/20/

45 Overcoming Medication- Related Barriers Presentations facilitated by: Stephen J. Kogut, PhD, MBA, RPh ~ University of Rhode Island College of Pharmacy Jackie Costantino, RPh, MBA & Jonathan Mundy, RPh, MBA ~ South County Hospital Medication Reconciliation Transitions of Care Lynne Driscoll, RN, CCM ~ South County Hospital Improving Medication Management during Transitions of Care A Collaborative Effort Safe Transitions Learning & Action Network Event September 20, 2012

46 The PDSA Way Medication Reconciliation Transitions of Care Jonathan M. Mundy, R.Ph., MBA South County Hospital Healthcare System Director of Pharmacy & Disease Management Services Safe Transitions Learning & Action Network Event September 20, 2012

47 Background Plan Problem: No formalized system for.. Completing an accurate Medication History in the Emergency Department Completing a comprehensive Medication Reconciliation upon admission Completing a final and accurate Medication Reconciliation prior to discharge Result Physicians had no confidence in accuracy of our system Goal 1. Establish an interconnected system for accurately documenting and reconciling a patient s medications and ensuring that once complete, this information is shared with the patient and the patient s physicians 2. Define specific metrics for documenting Pharmacy Interventions 3. Attain a 90% Pharmacy completion rate on all phases of this system; ED, Admission, Discharge Safe Transitions LAN, 9/20/12 3

48 Do Intervention/Project October established a dedicated Pharmacist position solely responsible for performing Medication Reconciliation on all inpatients January began training Pharmacy Technician s on performing Medication Histories in the Emergency Department January 2012 began using external medication list Dr. First to view and verify a patient s community pharmacy medication history January 2012 established stand-alone Medication Management Clinic April 2012 deployed trained Technicians to the Emergency Department to begin performing Medication Histories May 2012 began utilizing 5 th & 6 th year Student Pharmacists from URI, MCPHS, and Albany Colleges of Pharmacy to perform Medication Histories in the ED, and Medication Reconciliation on Inpatients Major Partners: Administration, ED Physicians, Hospitalists, Case Management, Primary Care Physicians, Nursing, Nurse Care Managers Safe Transitions LAN, 9/20/12 4

49 Study Evaluation/Data Data collection joint effort through Case Management and Pharmacy Pharmacy established 16 individual metrics to track specific interventions Pharmacy Technicians/Student Pharmacists account for 33% of the admission histories done in the ED Jointly, 98% of discharged patients are seen by Pharmacy & Case Management Individually, 90% of discharged patients are seen by a Pharmacist Results Physician confidence now very high Learned: Need to refine metrics - Do a deeper dive into what interventions are being made during a reconciliation and ask why Concerns: Knowing that medication list at discharge is truly accurate Safe Transitions LAN, 9/20/12 5

50 Act Next Steps Expand program - Educating Patients on their Medications - HCAHPS Expand program longer hours during the week and weekends Implement Patient Portal for Pre-Admission Testing patients Increase utilization of Medication Management Clinic Include community Pharmacy in information loop at discharge Incorporate into Pharmacy Residency Program beginning July 2013 Barriers Pharmacy Resources (Pharmacists and Technicians) Off shift and weekends Obtaining drug information patients, care givers, external sources Perceived value - Patient Safe Transitions LAN, 9/20/12 6

51 Collaboration The PDSA Way Advice for others Don t over analyze your startup Don t make the process complex Meet often with staff involved Ask them what works/doesn t work Expect to make lots of changes Most of all Partnership opportunities Primary Care and Specialist Physicians, Community Pharmacy, Long-Term Care Pharmacies, Rehab & Skilled Nursing Facilities Safe Transitions LAN, 9/20/12 7

52 The PDSA Way Improving medication management during transitions of care a collaborative effort Lynne Driscoll, RN, CCM South County Hospital Washington County Transitions Coalition

53 Problems Identified Lack of available medications with transfers No DEA number or lack of refills Lack of communication and respect

54 NO DEA and NO refill information Lack of required information The patient will not have the prescription filled Risk for pain and anxiety Decreased patient and family satisfaction

55 Increased communication Nurse to Nurse report using SBAR to assist with pain assessment and medication prior to transfer Nursing facilities are all using Interact Tool Ongoing Shadowing program to assist with transitional improvements and relationship building

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57 Case Management Reviewing and clarifying orders prior to transfer Faxing medication orders directly to the facility pharmacy to expedite access to patient Fax to facility prior to transfer for review and questions Assisting nursing with report and paperwork

58 Sample Faxes

59 Hospital commitment to Safe Transitions Medication reconciliations in the emergency room by pharmacy M-F Medication reconciliation by full time pharmacist on discharge M-F Out patient MTM program

60 Outcomes Improved assess to medications for patients prior to transfer and upon arrival to facilities Improved adherence and review of prescriptions prior to transfer Ongoing relationships with the community of care. Respect and ongoing evaluation for improvements and interventions.

61 Participants South County Hospital Westerly Hospital Primary Care Providers Hospital Doctors Nursing Home Medical Directors Apple Watch Hill Apple Clipper Westerly Health Center South Kingstown Rehab Center South County Rehab Center Roberts Health Center Scallop Shell South Bay Manor Bright View Commons Nurse Care Managers Visiting Nurse Health Care Services South County Quality Care Home and Hospice of RI Odyssey Health Centric Advisors

62 Washington County Coalition Shadowing Program Spend a day in my Shoes Sue Dubuc Nurse Case Manager ~ SCH & Kelly Cookson - Admission Scallop Shell SCH) Nina Liang - Nurse Case SCH & Roy Harley Social South County Nursing and Rehab Lisa Johnson- & Danielle Petit South Bay Manor Holly Fuscaldo - BSW Case SCH & Maria England-Berdy - South Kingstown Nursing and Rehab